Provider Demographics
NPI:1144817065
Name:BOTROS, MENA NAZER HALIM
Entity type:Individual
Prefix:
First Name:MENA
Middle Name:NAZER HALIM
Last Name:BOTROS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 CEDAR MOUNTAIN DR
Mailing Address - Street 2:
Mailing Address - City:STEPHENS CITY
Mailing Address - State:VA
Mailing Address - Zip Code:22655-4533
Mailing Address - Country:US
Mailing Address - Phone:848-234-8388
Mailing Address - Fax:
Practice Address - Street 1:46440 BENEDICT DR STE 103
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:VA
Practice Address - Zip Code:20164-6602
Practice Address - Country:US
Practice Address - Phone:571-926-8786
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-26
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVRP0012473183500000X
VA0202219167183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist